SoFHA
Patient Forms

MRI Screening

Description:

The SoFHA Imaging Center MRI screening form.

Code:

19.007

Issued:

01/01/2022

Revision:

Revised:

N/A

MRI Screening

Legal NameFirst, MI, Last

Date of Birth

MRI Body Part Type

Weight

Have you ever had any surgery on this body part?

Yes No

Have you ever had any x-rays or scans done this body part?

Yes No

Reason for MRI

Is this problem related to an injury?

Yes No

Are you claustrophobic?

Yes No

Have you ever been given MRI IV contrast (NOT CT contrast) before?

Yes No

Do you have a history of asthma, allergies or breathing problems?

Yes No

Are you diabetic?

Yes No

Are you currently taking medication for high blood pressure?

Yes No

Do you have kidney/renal failure?

Yes No

Are you currently on dialysis?

Yes No

Female Only

Date of Last Menstrual Cycle

Is there ANY chance that you could be pregnant?

Yes No

Are you currently breastfeeding?

Yes No

Do you have any of the following implants inside or on your body?

Brain aneurysm clip or coil

Yes No

Cardiac pacemaker, pacemaker wires or implanted cardiac defibrillator

Yes No

Electronic implant or pump (insulin, pain or medication) or external TENS unit

Yes No

Implanted neurostimulator

Yes No

Stents, coils, filters

Yes No

Cochlear, otologic or other ear implant

Yes No

Hearing aid (must be removed)

Yes No

Freestyle Libre or other diabetic glucose monitor

Yes No

Clothing with Dry Weave, Dry Fit, Tommy Copper, Copper Fit, moisture wicking, etc.

Yes No

Prosthesis (eye, penile, heart valve, breast)

Yes No

Eyelid spring/wire or magnetic eyelashes/mascara

Yes No

Metal shrapnel in or removed from eye

Yes No

Injury by a metallic object (bullet, BB, shrapnel)

Yes No

Medication skin patches (nicotine, hormone, Nitroglycerin, etc.)

Yes No

Artificial or prosthetic limb

Yes No

Metal breast tissue expanders

Yes No

Dentures, partials or other removable dental work

Yes No

Tattoo or permanent makeup

Yes No

Body piercings (must be removed)

Yes No

Joint replacements, screws, wires, metal plates, etc.

Yes No

Any surgery in the past 4 weeks?

Yes No

Anything else implanted inside or on your body that you weren’t born with?

Yes No

WARNING: Certain implants, devices or objects may be hazardous to you or may interfere with the MRI procedure. In rare cases, MRI can induce some heating of the body that could result in a burn. If you experience this or have any other problems, please inform the technologist.

You MUST remove & lock all listed items in a secure area: cell phone, watch, wallet, FitBit activity tracker, magnetic bracelets, keys, pocket knife, ankle weights, steel toed shoes, etc.

I attest that the above information is correct to the best of my knowledge. I understand that an image enhancement agent may be injected as part of this procedure. I was provided an IV contrast medication guide. I also consent to the release of radiographs, other imaging, post-op notes or reports from any facility if needed to help in the interpretation of this procedure.

Signature

By typing your name in the signature fields below, you consent to all of the agreements listed in this form. You furthermore agree that your submission of this form, via the "Submit Form" button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.

Patient/Guardian Signature